Form 10a100 - Kentucky Tax Registration Application printable pdf download

10A100 (2-05)

FOR OFFICE USE ONLY

KENTUCKY TAX REGISTRATION APPLICATION

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

Important — Please see instructions for details on

P.O. Box 299, Station 20

completion. Print or type the application using blue or

Frankfort, KY 40602-0299

NAICS

black ink. Incomplete or illegible applications will delay

Call (502) 564-3306 or

Need Help?

processing or be returned.

visit .

SECTION A

REASON FOR FILING THIS APPLICATION (Must be completed)

Effective Date: __ __ / __ __ / __ __ __ __

Previous Owner’s Account Numbers:

Opened new business

Kentucky Withholding _______________________

Resumption of business

Kentucky Corporation Income ________________

Registering to collect Kentucky use tax

Kentucky Sales and Use ____________________

Opened new location of current business

FEIN __ __ – __ __ __ __ __ __ __

Applying for additional tax accounts

Not applicable

Change in Ownership:

Your Current Account Numbers:

Ownership Type–Previous type ______________

Kentucky Withholding _______________________

Purchase of existing business

Kentucky Corporation Income ________________

Other (specify) ______________________________

Kentucky Sales and Use ____________________

Updating Information (See instructions—You do not

FEIN __ __ – __ __ __ __ __ __ __

need to complete the entire application.)

Not applicable

SECTION B

IDENTIFY YOUR BUSINESS OR ORGANIZATION (Must be completed)

Legal Business Name __________________________________________________________________________

DBA _________________________________________________________________________________________

Federal Employer Identification Number (FEIN) __ __ – __ __ __ __ __ __ __

Business Location—Street Address (Do Not List a P.O.Box) ___________________________________________

_____________________________________________________________________________________________

City __________________________________________

State __________

ZIP Code __________________

County __________________________________

Location Telephone ( _____ ) _____ – __________

A Give a description of the nature of your primary business activity outside Kentucky. Include a description of any

services provided. ____________________________________________________________________________

B Give a description of the nature of your primary Kentucky business activity. Include a description of any

services provided. ____________________________________________________________________________

C NAICS Code: (optional) __ __ __ __ __ __

If you make sales, list products sold: ________________________________________________________________

Accounting Period:

Calendar Year 12/31

Fiscal Year: __ __ / __ __

Partnership:

Ownership Type:

Sole Proprietor

General Partnership

Corporation

Limited Partnership

S Corporation

Limited Liability Partnership (LLP or LLLP)

Limited Liability Company:

Government

Association

Taxed as a Sole Proprietorship

Fiduciary

Taxed as a Partnership

Joint Venture

Taxed as a Corporation

Real Estate Investment Trust

Taxed as an S Corporation

Trust

Taxed as a Disregarded Entity:

Nonprofit

Member taxed as: __________________________

OWNERSHIP DISCLOSURE—RESPONSIBLE PARTIES (Must be completed)

Name

Title

Residential Address, City, State, ZIP Code

Soc. Sec. No. (Required)

CONTACT PERSON (Must be completed)

Name (print) _______________________________

Title ____________________________________________

E-mail Address (optional) ____________________

Daytime

Telephone

( ______ ) ______ – _________ , Ext._______

(By supplying your e-mail address, you grant the Department of Revenue

permission to contact you via the Internet.)

Fax

( ______ ) ______ – _________

IMPORTANT: APPLICATION MUST BE SIGNED BELOW.

The statements contained in this application and any accompanying schedules

are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly authorized to sign this application.

Signed ____________________________________________ Signed ___________________________________________

Title ___________________ Date __ __ / __ __ / __ __ __ __ Title __________________ Date __ __ / __ __ / __ __ __ __

Form 10a100 - Kentucky Tax Registration Application

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